School of Public Health & Community Medicine, University of New South Wales (UNSW), Sydney, Australia.
Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
Int J Equity Health. 2018 Oct 5;17(1):93. doi: 10.1186/s12939-018-0805-1.
Contracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh's two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries.
This qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes.
In Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project's ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts.
This study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.
将业务外包给非国家提供者是广泛用于增加医疗保健服务可及性的一种手段，但它带来了许多实施挑战。本文利用孟加拉国在城市初级卫生保健业务外包方面的二十年经验，确定了在中低收入国家实施业务外包时需要考虑的背景、合同和相关行为者因素。
本案例研究采用定性方法，对过去和现在与政府和城市初级卫生保健项目合作的利益攸关方进行了 42 次深入访谈，并对关键项目文件进行了案头审查。利用卫生政策三角框架来区分多种相互交叉的背景、合同和相关行为者因素，这些因素是影响复杂实施过程的特征和因素。
在孟加拉国，卫生系统内外的背景因素对业务外包过程产生了深远影响。这些因素包括与其他卫生项目的竞争、公共部门改革以及更广泛的国家层面政治和官僚环境。在合同中规定了向穷人提供免费服务和收回成本的目标，这两个条件相互矛盾，服务提供者难以同时实现。在行为者方面，执行机构的选择导致了一些复杂问题，使地方政府机构（城市和直辖市）在管理业务外包过程方面的功能被削弱，并阻碍了业务外包安排融入更广泛的国家卫生系统。政治和权力动态破坏了项目区域的道德选择。最终，这些因素和其他因素削弱了项目实现其最初目标之一的能力：下放管理责任和发展城市管理合同的能力。
本研究提请注意在孟加拉国和类似国家成功实施业务外包项目需要解决的因素。国家自主权对于将业务外包纳入国家卫生系统至关重要。必须同时确保开展地方业务外包能力建设。业务外包模式必须具有适应性和对不断变化的背景做出反应的能力，同时在商定的和适当的法律框架内运作，并具有坚实的道德基础。
